On the other hand, it just confirms that the profit driven health insurance system stinks -

1:27 pm February 13, 2008

JW wrote :

Government health care for all is coming in one form or another... get used to it. The health insurance companies have brought it onto themselves.

1:30 pm February 13, 2008

Dan wrote :

The irony is that Doctors and Hospitals depend on insurance companies like crack addicts depend on their pushers. Do you REALLY think that if tomorrow, magically, healthcare went to an entirely cash basis, that ANYONE could afford what MD's currently charge? Would anyone pay 10X the cost for Lipitor over a generic, if it was coming directly out of their bank accounts?

The irony of MD's and hospitals going after the insurance companies that enable their fleecing of the American healthcare dollar is amazing.

But it does make following these blogs really interesting...

2:28 pm February 13, 2008

Connecticut Doc wrote :

We doctors have allowed ourselves to be screwed by third party payors for years. Maybe Cuomo's road show will motivate CT AG Blumenthal to join in.

A few years ago, thanks to the insurance companies' underwriting their GICs with junk bonds, all the mutual health insurance companies suddenly found themselves having to go public to stay in business. When health insurers were owned by the policyholders things were pretty much ok. But now that they have been public profit making machines for the past ten years, not a person in America doesn't have a health care problem - except of course, congressmen and senators - all their stuff is taken care of by the gov't.

Our elected Congress who just won't touch this issue for the rest of us are fond of saying 'Let the marketplace decide.'

Folks, stop buying into this crap already. Enough. The marketplace is fine for folks who profit from selling their stuff to you. Health insurance only makes a profit by withholding their product from you - from NOT paying claims. Don't you get it yet?

4:10 pm February 13, 2008

CT IPA Doc wrote :

I'd like Cuomo or CT AG Blumenthal to up the ante...file a RICO suit against United and all these insureres. This is a massive conspiracy and fraud. While the antitrust laws and the FTC keep physicians disaggregated and powerless, insureres are free to collude and act like the good oligopsonists they are.
Physician fees have been flat or declining for years, while insurance premiums, health plan profits and, especially, health plan CEO compensation are off the charts. Soon they'll be no PCPs left. Way to go United.

4:19 pm February 13, 2008

Scott wrote :

Dan- “Do you REALLY think that if tomorrow, magically, healthcare went to an entirely cash basis, that ANYONE could afford what MD’s currently charge?”

No. But let’s say we went to a cash system, provider prices would fall dramatically, because now the provider would have to be competitively priced so that the CONSUMER could afford the cost. Providers would finally have incentive for transparency and competitive pricing.

The price a provider charges are for big corporations and the government to pay. But what happens when you the patient are denied benefits from either your insurance company or government plan? The consumer is stuck paying for industry prices.

However, provider pricing is a reaction to the price controls and less then fair market value reimbursement from third party payers. Then third party payers turn around and jack up your premiums because “healthcare is expensive” and then when no one is looking, cut provider reimbursement rates. What do think the providers reaction is to that? Ah, yes the cycle starts again. Where is the consumer in all this….. the one entity that is ultimately financially responsible? Dunno, but definitely not part of the “market”.

This whole industry could benefit from some transparency. I applaud New York’s Attorney General Andrew Cuomo for taking on this U&C scam.

4:44 pm February 13, 2008

Jim wrote :

This is a zero sum game. The doctor charges some dollar amount. The insurer pays part of the charge. The employer pays part of the charge (through premiums) and the insured pays whatever is left over. Insurance company's profit is highly regulated, especially in the state of NY. Yes, they do make consistent profits but rarely excessive profits. The only piece of the puzzle that is uncontrolled and unregulated is what the doctor charges (where is the outrage on that????). All the insurer can do is make an estimate as to what doctors will charge (probably based on what they have actually charged in the past). That is how insurance works. The insurance company says most of the time some procedure will cost $x and will happen y times. Then tack on $z to cover the insurers expenses (and profit). There is your premium. If you want the insurer to pay more, increase $x. y doesn't change $z doesn't change. It is a pass through to the employer and/or insured. It's not a charity, it is not a single payor system. It is a business. If the cost of services increases, guess what, the cost of insurance increases.

5:12 pm February 13, 2008

gfellow wrote :

Way to go Cuomo. Kick some of these insurance comapnies, where it hurts. They milk the policy holders by increasing premiums every year, and they milk the doctors by cutting payments or denying claims every year

6:02 pm February 13, 2008

Texas Doc wrote :

UnitedHealth care is nothing more than the WORST insurance company there is. I have come to the conclusion that they are nothing but thieves.
Here in Texas, they have been fined multiple times for delaying payments to physicians--many times for up to 8 months. My office got tired of their constantly 'lost' claims--and these were electronic claims. Then my staff had to spend hours on the phone with their 'provider reps'--very nice but utterly incompetent people in India and the Phillipines who have ZERO authority to actually get anything done. All they do is constantly apologize and ask you to 'wait for the claim to be processed.' Of course, United has a very short filing deadline and if you keep waiting, then you have missed the filing deadline.
This year I have dropped United. I am sorry for the patients that were on it, but they just need to understand that having United is just like having NO INSURANCE. This company deliberately does not want to pay claims so they can inflate their earnings and keep their stock price up. I can't wait to see the price of the stock plummett to the ground--which will happen as more business and physicians drop United.

6:13 pm February 13, 2008

Scott wrote :

“The insurance company says most of the time some procedure will cost $x and will happen y times. Then tack on $z to cover the insurers expenses (and profit). There is your premium. If you want the insurer to pay more, increase $x”

That’s not the case. If the provider increases $x does not mean at all the insurance company will pay more. One; if the provider is a contracted provider, the provider will get a set fee for services from the insurance company regardless of the “price” of x. Two: if there are no contracts between the provider and carrier the provider will get reimbursed based on U&C rates. Now most people think that U&C rates are an average price for a procedure in given geographic region of providers (also known as a geozip). So, like you stated, one would think that, hey if all the providers raised their prices, then the average U&C rate would rise as well. Sounds logical. However, that’s not how U&C works.

I’ll try an explain the best I can; U&C is a percentage of a percentile. Somewhere in the world UHC has this data base called PHCS (Prevailing Healthcare Charges System developed by Ingenix) and they have figured what the highest to lowest prices are for a given procedure in a geographic region. So now they assign percentile’s to those prices. 100 percentile being the highest price and 0 percentile being the lowest (it’s never a 0% but in this example we will use that). Now within those percentiles there are percentages that make up that percentile ( 90%of 100th percentile, 80% of 100 percentile and so on). So carriers have determined what percentage of the percentile they are going to pay at and it can vary wildly from carrier to carrier. For example: my States workers comp fee schedule for physicians, which is based off of usual and customary (the PHCS data base) the rate is 90% of the 80th percentile. So again, no matter how much the provider charges, the WC carrier paying off my States fee schedule will only pay 90% of the 80th percentile. Another example is Medicare. Medicare rates for a doctor’s visit (99213) in my locality fall on 40% of the 30th percentile (btw: Medicare does not determine rates based in the PHCS data base. I was just saying that’s where the rates would fall on the U&C scale for my locality).

So it’s not an average, and the U&C percentage of the percentile rate is never disclosed by carriers. However, from me knowing what my States WC fees are at (per CPT and geozip) and knowing that they use the PHCS data base, I have developed a mathematical equation which tells me exactly what percentage of a percentile carriers are using / paying at (and it’s all over the board).

6:16 pm February 13, 2008

Anne PME wrote :

What all of the health care policy people and others who support govt backed universal health care fail to realize is that big insurers will prevail. Companies like United, Wellpoint(Anthem)and Aetna are the only companies equipped with nationwide provider networks and medical billing systems that are already in place. These companies already serve as fiscal intermediaries to gov't run health programs. If we move toward a govt backed system, big health insurers will make more money, not less.

6:24 pm February 13, 2008

The Truth wrote :

Insurance companies have been cheating patients and doctors for a long time. Physicians should mobilize and speak out. This link tells the story of a campaign and may just work for physicians tell their side of the story to the American public: http://blog.seankhozin.com/2008/02/12/test/

6:54 pm February 13, 2008

gfellow wrote :

If united pays $60 for an office visit (code 99214) in NJ, and Medicare pays $101, then either medicare is stupid, or United healthcare is ripping off physicians and thereby forcing them to cut quality of care.

6:59 pm February 13, 2008

gfellow wrote :

Here is another place where Americhoice of NJ, which is owned by the infamous United Healthcare is ripping off the NJ medicaid program. They are a Medicaid HMO. If the patient has medicare as primary, and medicaid as secondary, and he/she signs up with Americhoice as a medicaid HMO, then Americhoice refuses to cover the copayments left over after medicaid pays. Other Medicaid HMO's like Amerigroup covers this gap. This way Americhoise is ripping off NJ medicaid by taking the money from NJ medicaid to take care of its patients, but not paying any claims on it. Great 100% profit.

9:45 pm February 13, 2008

Get Real wrote :

Here is the real scoop...

1. Health insurance companies do not provide health care. Doctors and staff in hospitals and facilities provide health care. If you die because you are denied healthcare, your insurer didn’t fail to treat you because they weren’t going to be reimbursed. It was your dr. or your hospital that failed to treat you because they weren’t going to get reimbursed. All your insurer tells you is whether or not your treatment will be funded by the plan you have with them. If you believe that it should be funded, appeal the decision. You have that right. But don’t sit there and exonerate your provider for letting your illness get worse. We, as consumers, need to hold providers responsible for the care they provide to us, not insurance companies.
2. Health insurance and managed care companies provide 2 things: 1. Coverage for a limited range of your health care expenses based on the plan that you or your employer selects. It is all about price. If you want a high benefit plan, you will pay high benefit prices. Regardless, it is your responsibility to read the documentation provided by your plan and know what is covered and what isn’t. If you don’t have the documentation, call your plan and ask. 2. They provide administrative services for your healthcare financing. They mitigate risk, pay claims, consolidate provider information, provide service discounts, and a range of other services. For getting these services, you and your employer pay a fee. If you don’t think you are getting your money’s worth for the services, find another company that does it better and faster and cheaper. Know what you are paying your insurance company for and what you are paying your doctor for. Once you get that straight, demand quality service from both. Hold your insurer accountable for providing quality services and mitigating your risk as required by your plan and the law. And Dr’s . . . You are discount suppliers of healthcare services to consumers through distributors (health insurers). If your distributor doesn’t pay you timely, or enough, or correctly, then stop supplying to them. Term your contracts. Distributors need good suppliers. Without them, they lose market share. Losing market share means losing profit and investors. That is your leverage. But, don’t blame them for your poor provision of care or their making a profit.
3. Here is the elephant in the room. In this country, you are most likely covered by your employer. If it is a larger employer, chances are your group is self funded. Ask your benefits administrator at work if your plan is self funded. If it is, your employer decided what services were covered and which weren’t, not the insurance company that administers the plan for them. This includes pre-existing exclusions like the one noted in this article. All the heath insurance company does is pay the claims under plan provisions, answer the phones, and provide the other services noted above. This is called Administrative Services Only (ASO). For this, they charge your employer an administrative fee called a Per Member Per Month (PMPM). The PMPM covers the administration of the benefit provisions of the plan, but not the costs of covering the risk of the plan. That risk is maintained by your employer as part of the self funded plan. The health insurance company makes its money on an ASO contract by completing the administrative duties at less cost than the PMPM for administering them. If your employer wanted to cover any level of treatment at 100% on a self funded plan, any health insurance company would be happy to administer the transactions that would make that happen. Just pay the PMPM. If your benefits are too limiting, it is probably because they are the ones your employer selected for you.
4. Profit is already in health care at all levels. It is in medical insurance, medical supplies, buildings, DME, professional services, drugs and every other aspect you can think of. You can eliminate the health insurance company profit, but that doesn’t take profit out of healthcare. Next time you leave your dr’s office, check out the car she drives. Chances are it is not a 1975 Dodge Dart, and it is probably nicer than yours. Whose profit bought that? National surveys of income place dr’s in the highest class of earners in the country. How does that compare to what most people make? One person’s costs are another person’s profits, plain and simple.

9:45 pm February 13, 2008

Get Real wrote :

5. Nationalized funding healthcare does not solve any of the 4 issues above. It certainly won’t remove profit in providing healthcare. If it did, econ 101 tells you will contract the supply of providers, making access more difficult. Additionally, increased “income” provided by the government for consumers of healthcare services delivered in this environment (contracting provider supply) would increase demand, further exacerbating the access issue noted above as more people went to see fewer providers. This is what we see now in countries with nationalized or socialized medicine. In the US, almost 50% of healthcare services are being funded by our governments at rates that undercut provider costs. Medicare and Medicaid have provided access to consumers (a good thing) that is paid for at current rates below the cost of production (a bad thing). Those programs, which were funded at more cost competitive levels years ago, now account for a significant portion of the problems today. Demand has increased. Costs have increased. Rates, supply and efficiency have not kept pace. Costs and profit have to be made up somewhere and the private pay, non-contracted world is the place. Shifting more control to the government will only make it worse.
6. The long term solutions are to increase the supply of health care providers and make delivery more efficient. Also, to make consumers of healthcare services more aware of price and quality outcomes when selecting providers. Without a more efficient delivery system, our costs will continue to sky rocket, no matter who the ultimate payer for services may be. And without consumers being truly sensitive to the costs their lifestyles add to our medical spending and what a quality medical outcome is, we will continue to see demand curves that create upward pricing pressure.

10:42 pm February 13, 2008

Anonymous wrote :

Couldn't have said it better myself Get Real! The only thing I will add to your comments is the fact that if we ever move to a federal healthcare system, we will be openning the system up to ALL & EVERY special interest out there. Considering that liberal politicians have an inability to ever say "no" to anyone or anything, we will only further be adding cost to the system by mandating all kinds of expensive coverage. National healthcare would be the worst economic train-wreck this nation has ever seen.

10:59 pm February 13, 2008

VeteranRep wrote :

I think Cuomo should double check the government's own reimbursement rate for underpayment at the same time he leads the crusade against a public company. Last I checked, the government was far lower than any private insurance. Ask your physicians about Medicare and it's threaten %15 reduction for office visits. I find this crusade supremely hypocritical...or at least one-sided. Of course, if you follow the money, I will bet that Cuomo and others suddenly receive more campaign money from insurers the next election.

8:40 am February 14, 2008

Also Anonymous wrote :

Way to go, Cuomo! You are shooting fish in a barrel here, my friend. I'm sure yor preliminary investigation confirmed you have enough of these claims to go on. It's well known that the for-profit insurance companies DELIBERATELY set up multiple "fee schedules" and tell patients and providers when they question the low amount that their reimbursements are based on 'HMO, Plan A, Group B' and make it so confusing and time-consuming that patients and providers give up. This game has been well-gauged by the insurance industry and they employ thousands of statisticians who tell them how many patients or providers complain or appeal. I'm betting the number is less than 20%...and the insurance companies are probably betting the same odds!

When a physcian suggests a test or treatment and a patient decides against it for any reason, why is the physcian held responsible?

If the insurance company wont pay for it why should the physician?

9:59 am February 14, 2008

Richard Wilson wrote :

I don't think it is shocking but right on this suit or not it is good to have a few leaders out there policing the industry. There are many niches within it that are laregley untouched by audits or regulations.

In NJ, private insurances reimburse at around 60% of Medicare for office visits

10:47 am February 14, 2008

Randy Crenshaw, MD wrote :

Recent data show that 85% of Americans spend less than $5000 a year on medical care. High deductible health insurance policies are tailor made for those millions of purchasers. If those millions of shoppers spending their own cash hit the streets looking for better value in health care, AG Cuomo would have no one to sue. The patients would decide what is "reasonable & customary".

1:13 pm February 14, 2008

realist wrote :

A mid-sized manufacturing company in Wisconsin developed an in-house medical care system and provided excellent medical care for its employees and saved $6000 per employee in their costs. The health-care providers were happy, the patient-employees were happy. The insurers who got cut out of the deal were very, very UNHAPPY! The cost of healthcare would plummet if the huge companies who are profiteering, i.e. United Health, Aetna etc., were cut out of the equation.

Wake up America. The managed care industry is fleecing us all!

2:46 pm February 14, 2008

It Can Happen to You, TOO wrote :

I have had to deal with this situation twice, for procedures to halt a cancer that affects 4 people in 1 million. Usual and customary is absurdly low, considering there are only 2 doctors in this specialty in the NY Metro region, and they both charge similar fees. I am out more than $6,000 because of this. Cuomo is right, certainly in my case.

How ignorant can you be? You are already paying for the current doctors fees and more. It is called your annual health care insurance.
The problem is more about what you are getting for it. That is where the Insurance companies are subverting the system.
As for your assertion that noone would pay for lipitor when generics are cheaper, why do you the patient look at all those ads want more consumer health care and stick the bill to a 3rd party payer.
There is plenty of blame to go around. However, the Insurance companies have taken things to the depths or monopolistic practice.

8:42 pm February 18, 2008

Cirrus wrote :

I hope you all realize that insurance companies have 30% overhead due to "administrative costs." Which are of course, mostly because they spend all their time denying and underpaying claims, and then proceed to waste more time fighting with the patient (assuming the patient has the energy left to fight).
I've had two different insurance companies attempt claim that I had visited a doctor out of network without notifying them so they weren't going to cover it. Except...the doctor was my PCP, and he was definitely billing in-network. But, since they insist on trying every last trick to not pay the bill, Aetna told me that I had seen the doctor THEN switched to him as my PCP (patently untrue of course).
So I wasn't too surprised when the EXACT same thing happened to my mother with Oxford. She had switched primary care doctors AN ENTIRE MONTH PRIOR (due to her doctor retiring) to her visit, and Oxford still claimed that she had switched after her visit.
Possibly the most ridiculous was when Aetna (again) tried more ridiculous tactics (and wasted a good deal of their claims processing labor costs) to try and deny a $40 bill. I have no idea what rationale they could have had for wasting what must have amounted to an entire hour of man-power to attempt to deny a $40 claim...but they did wasted that and some postage just to try to and deny a $40 claim when they're being paid thousands of dollars a year and I typically use like $300 of healthcare a year.
Anyways, these "customary" charges can be any number they feel like making up-that's the whole point of the lawsuit. And of course, the problem is that if they set their in-network rate to something absurd, doctors simply won't take their insurance. But of course then the problem is that this just leaves them free to make up any number and nobody will negotiate this with them.
No other insurance works with this insane logic that health insurance uses. It would be like your homeowner's insurance deciding how much your house was worth after it burns down, and ignores how much you paid for your home and your possessions and instead decides to arbitrarily decide what's a reasonable amount. So because they feel that the customary payment for a burnt down couch in your neighborhood is $40, you're going to get $40 for that couch. And when you ask them whose couch had ever actually been worth $40, they won't tell you how they got that number, and even if they did it was probably based on the $40 they told the other guy next door was the customary reimbursement.
Anyways, doctors made plenty of money before everyone had health insurance, and their income has only dropped in the last decade so they're not the ones causing this idiotic rise in healthcare costs.

11:50 pm February 19, 2008

FreedomGuy wrote :

Get Real got the first part right. Insurers don't provide healthcare, but they do pay the bills. The rule in all of life is that "Whoever pays the bills calls the shots." It applies whether you are buying stuff for your kids or your employer buys stuff for you. Insurers have the advantage due to government rules and tax laws. They directly pay the bills and are the only ones that know the true costs...and they don't share the information with us. Your employer pays the insurers so they have an indirect say in things, but not directly unless they self-insure. If government pays the bills they will (and do) make the rules, too. I say, let us have our own tax-deductible accounts and let us as individuals contract for lifelong insurance like we do on our houses, cars and life policies. No individual would put up with the garbage that you get under the current system and we would not allow insurers to make our physicians so miserable. I know of no other way to get some balance in the system. A single payor system will be just as bad or worse, too.

4:31 pm February 20, 2008

Anandi ji wrote :

All insurance companies and Health Care providers whether they are Internists, Hospitals and Licensed Alternative Practioners should accept all insured patients. Quibling over pricing at what cost is our health?

One of the reasons why some doctors charge more than others is for the most part location, location, location..

The US healthcare system is corrupt and will be bankrupt if the US government doesn't do something Now!

1:27 pm February 22, 2008

docbklyn wrote :

Doctors might drive better cars than a "1975 Dodge Dart", but what people fail to see are the insurance company CEOs flying overhead in their private jets. Doctors actually render health care directly to patients. They have greater education and training than most people -- why shouldn't they be among the highest wage earners? What is wrong is the insurance company execs who get rich by denying care to the patients who pay the premiums and denying payment to the doctors who take care of patients. The doctor is the only irreplaceable member of the healthcare system. Get angry at the unknown, unseen corporate exec in his Gulfstream jet, being rewarded for leaching money out of the system. Don't hate your doctor for (maybe) driving a slightly better car than you do.

10:19 pm January 13, 2009

Primary Care Physician wrote :

I feel like this problem that Mr. Cuomo is tackling is not a problem that impacts the majority of patients. In my area, people just do not go to out of network doctors or hospitals. I admire Mr. Cuomo for his efforts to hold the health insurance companies' feet to the fire. What I would like to see is a fire-eating lawyer like Mr. Cuomo go after the issues that really make the practice of medicine, especially for primary care physicians, difficult. Out of network providers are mostly specialists - Diagnostic imaging companies, orthopedic specialists, dermatologists, plastic surgeons. I would like to see a lawyer of Mr. Cuomo's calaber fight the federal laws that prohibit sale of health insurance across state lines for small businesses and individuals. Go after the HMO's that impose ridiculous paperwork requirements. Give doctors more power and authority to say "No, your paperwork is a waste of my time. You can't make me do it". Go after the laws that give people unrestricted access to emergencies rooms for whatever complaint they have regardless of whether it is an emergency or not. Go after insurance companies who duplicate credentialing paperwork that has already been done by ten other hospitals and insurance companies. Go after insurance companies and say they must limit their advertising and administrative costs to certain % of operations. Go after insurance companies and tell them they must accept anyone who applies regardless of pre-existing condition. Limit premium increases. Ban direct to consumer advertising of prescription medicines. Tackling the issue of payments to nonpartipating providers just seems to me like picking at the edges of the problem. And it makes me doubt that Mr. Cuomo really has the guts to tackle the insurance companies and the pharmacy benefit managers where they really need to be hit. It's the participating, in-network primary care doctors who need some help.

12:13 pm March 3, 2009

Bill wrote :

Seriously, what's Cuomo problem?? I'm tired of him trying to act like the savior of the United States. Who is he to decide what's fair and what's not?? The sad thing is this is all politically motivated so that when he runs for governor again he will hopefully fair better than last time. He needs to stop going on these power trips. First with the financial sector and now health care again. GET OFF YOUR WHITE HORSE MR. CUOMO!!!! YOU"RE NOT AS GREAT AS YOU TRY TO PORTRAY YOURSELF TO THE GENERAL PUBLIC!!!

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